Within the past decades, the karst region in the Guangxi province in southwest China has been in the focus of large scale ecological restoration projects. In this study, we adapt the pressure-state-response (PSR) framework (which includes measures for human pressure, the current state of the ecosystem and the human response) and propose a remote sensing based ecosystem health (ESH) index (0–1; 250 m spatial resolution), evaluating the pressure and state of the fragile karst ecosystem. We further apply inventory data of recovery actions (restoration areas at county level resolution) as response to ongoing degradation to test the impact of ecological restoration on the ESH. Our analysis was conducted for the years 2000, 2010 and 2016, and the results showed that 73% of the study area experienced an increase in the ESH (from 2000 to 2016) which was related to the improvements in vegetation vigor, organization, resilience, ecosystem service provisioning which offset a deterioration in fragmentation and population density. From 2000 to 2016, areas of increase in ESH were slightly larger in karst than in non-karst (37.5% and 35.1%, respectively), but also larger areas of decrease in ESH were observed in karst as compared to non-karst (16% and 11%, respectively). The results further showed that the share of areas with a high ESH (greater than 0.7) had increased by ∼3% (from 67.16% to 70.21%) during the 17 years period. At county level, we found a clear relationship between increases in ESH and ecological restoration areas (r = 0.58, p = 0.004), with a high recovery rate (ratio between areas with increased ESH and restoration areas in a county) in karst than in non-karst. We conclude that restoration projects have caused a large scale transformation of farmland into forested areas (∼5500 km2), which has caused a general improvement in ecosystem parameters related to ESH.